David Cullinane (Waterford, Sinn Fein)
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I move:

That Dáil Éireann:

recognises that a succession of Fianna Fáil and Fine Gael Governments made decisions which caused and exacerbated the crisis in our emergency departments (EDs) today, including Fianna Fáil's decision to close thousands of beds in their last term in Government and Fine Gael's refusal to invest in an adequate number of beds over the past decade, which have left the public health service with less acute inpatient beds for the last 23 years than when the Tánaiste, Micheál Martin TD, became Minister for Health in 2000;

notes:

— the previous commitments to end the scandal of patients on trolleys made by the Fine Gael party and the Taoiseach, Leo Varadkar TD; and

— that the Taoiseach said that "ED overcrowding is a priority issue for me and for the Government" when he was Minister for Health in January 2015, and has said that overcrowding is "unacceptable" since returning to the Taoiseach's office, and considers that the circumstances in EDs have worsened significantly in the eight years since the Taoiseach became Minister for Health, and that the Taoiseach's rhetoric should be judged against his demonstrable record of failure in Government;

condemns:

— the failure of successive Ministers for Health and Governments to sufficiently invest in hospital capacity, primary and community care, and workforce planning to avoid the record high number of 931 patients on trolleys witnessed on 3rd January, as recorded by the Irish Nurses and Midwives Organisation;

— the current Government's dismal Budget 2023 which failed to provide any additional funding for new acute inpatient hospital beds, failed to set ambitious multi-annual capacity and bed targets, and failed to ramp up or set multiannual targets for healthcare professional training places at the pace which is necessary;

— the decision of the Taoiseach and Tánaiste to retain the same failing Minister for Health, Stephen Donnelly TD, in his post during the recent Cabinet reshuffle; and

— the Government's decision to ignore early warnings last summer of the risk of medicine shortages; and

calls on the Government to:

— immediately make greater use of all public and private health care infrastructure to alleviate pressure on the public system and to minimise disruption for public elective patients;

— increase the number of public beds in the system, including more acute inpatient and sub-acute hospital beds and community step-down beds to speed up admissions and discharges to meet rising demand and demographic change, to expedite the development of elective centres and hubs to provide protected scheduled care capacity in line with Sláintecare, and set out a multi-annual plan for achieving this;

— further increase the number of training places so that we can recruit and retain the doctors, nurses and allied health and social care professionals in sufficient numbers to staff the beds required in the public system on a long-term basis; and

— ensure that the Health Products Regulatory Authority, the Health Service Executive and the Department of Health are engaging proactively to resolve the shortage of medicines and to legislate for a serious shortage protocol to support pharmacists.

A failure to plan and a failure of leadership left patients and front-line healthcare workers high and dry during the winter period. In fact, the pressures that those on the front line are facing today are still as stark as they were in the first week of January. It has to be said that the experience of patients in emergency departments throughout our country, with overcrowding levels that we have not seen previously, was an absolute disgrace. I will be the first to accept that rising cases of flu, Covid-19, respiratory illnesses place pressures on the healthcare system, and they did but we cannot excuse the lack of capacity in our hospitals, we cannot excuse the fact that the winter plan was clearly insufficient and we cannot excuse the fact there was not sufficient leadership coming from the centre either politically or from the HSE leadership to ensure that patients were treated with dignity, that there was humane treatment of patients, as opposed to the inhumane treatment that so many people received, and that we had a health service that could offer the basic levels of care to patients. We all saw the images of trolleys in corridors of hospitals throughout the State. Some of those patients were elderly and some were there for days. They were only the patients waiting to be admitted. Many more waiting for care also waited long periods - in some cases more than 24 hours; in other cases, days on end. Some of them ended up sleeping on the floor in emergency departments.

I will focus on all the solutions that need to be implemented urgently by the Government. We know what we need to do in the short term when we have a crisis and a surge such as this. We have to prioritise care in emergency departments, redeploy staff and do all the things we know need to be done. That is crisis management. However, we have known for some time that hospitals simply do not have the capacity they need. Once and for all, we have to make a decision to put the beds that we need into the public system to enable decision makers on the floor of emergency departments to admit patients much quicker. We need more beds. We also need more staff, including consultants, doctors, nurses, healthcare assistants, radiographers and allied healthcare professionals. We need more diagnostic capacity. I have been saying that to the Minister for some time. The lack of diagnostic capacity in public hospitals makes it more difficult for decision makers to speed up the care for people in emergency departments. That in part is the reason people are waiting too long. All that capacity is needed in our hospitals. We also need to expedite the elective-only hospitals and the surgical hubs that were promised to ensure we have a separation of scheduled from unscheduled care. The capacity in acute care, including elective hospitals, and putting capacity into our hospitals, is the first priority.

The second priority has to be workforce planning. We have to increase training places substantially and ensure we have sufficient recruitment and retention strategies, and deal with all the contractual issues. We need to hire and train more staff to open the beds to provide the diagnostic capacity and to put the physical infrastructure that we need into the hospitals.

The third priority has to be right care, right place, right time. It sounds great. I have heard the Minister say that time and again. It is the cornerstone of Sláintecare but we have people who should be cared for outside of hospitals but the capacity is not there. What angered people during the month so far and in December was hospitals saying, "Do not come to emergency departments - avail of all the alternative care pathways that are available such as out-of-hours GP care, out-of-hours pharmacy care", only for many people to be left ringing numbers and not getting through. There was not a chance of them being able to avail of any of those services because the capacity was not there. We need more GP capacity, more out-of-hours capacity and more community intervention teams doing all the work that needs to be done.

The fourth priority has to be reform. We need good management and good leadership. It has to be said that what is called organisational grip, which in layman's terms is simply good management, is absent from many of our hospitals. We are not using the resources in the way that we should. We also have to expedite the regional health areas, RHAs, and get that part right where we integrate healthcare and not have the layers of management that we have. We need a single tier of management that can make decisions in regard to primary care, community care and acute care. We are not doing any of that. I believe that Deputy Donnelly has failed as Minister for Health properly to support our health services. I believe he should take responsibility for that and he should apologise to all the patients who were left without the care that they deserved. He should apologise to all those on the front line who have been left high and dry without the tools, the capacity and ability to deliver the safe care they want to deliver.

Matt Carthy (Cavan-Monaghan, Sinn Fein)
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The overcrowding we have witnessed in our hospitals this winter represents an inhumane, unsafe, undignified health service. We need radical action. Unfortunately, few people have confidence that this Government will deliver that because the cause of the unrelenting crisis in our health services is the policy agendas pursued by successive Fianna Fáil and Fine Gael Governments. I have seen it happening in real time in my political life in my county of Monaghan. I saw local elected representatives but, more important, local communities warn Fianna Fáil and Fine Gael Governments that if they were to remove services from Monaghan hospital, it would lead to increased pressure on Drogheda and Cavan emergency departments. That is what happened. We warned about this. I was actively involved in pursuing Ministers for Health in respect of a GP shortage that we were seeing in County Monaghan as far back as five years ago. Ministers say it is an operational matter. What did the HSE say? It said there was no shortage at all. Now throughout the State we have a recognition that primary care is in disarray. At least two decades of negligence have come home to roost. There are fewer acute inpatient hospital beds in hospitals than 25 years ago. In 2022, there was not a single day when there were fewer than 300 people waiting on trolleys. It is a scandal but the solutions are there. We do not need to learn any more lessons. We need to implement the plan that Deputy Cullinane outlined because overcrowding was declared a national emergency as far back as 2006. It has been allowed under the Minister’s watch and the watch of his predecessors to become the new normal. However, it is not normal. It is a national disgrace and it needs to be addressed. We need to implement the measures that Deputy Cullinane outlined such as adopting the multi-annual plan to increase the number of public beds, including more acute inpatient and sub-acute hospital beds and community step-down beds. We also need to speed up admissions and discharges. Most important, we need to ensure that those thousands of Irish healthcare workers who are scattered to the four corners of the world are brought home and that those currently envisaging such a prospect are enticed to stay here. What we need is for the Department and the Government to use a fraction of the effort they used to ensure that the Secretary General of the Minister’s Department is one of the highest-paid civil servants in the world. They should use a fraction of that manoeuvring to ensure our healthcare workers remain in our health service and are proud to do so, and we can be proud of the work they are doing on behalf of all our patients.

Mark Ward (Dublin Mid West, Sinn Fein)
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In the winter plan there was no provision for additional supports in emergency departments for people experiencing mental health difficulties. On average, we have 5,500 adults per year presenting to emergency departments with suicidal thoughts. That is an average of 100 people per week attending our emergency departments. Emergency departments are not an appropriate environment for anyone suffering from mental ill-health but because of the lack of access to 24-7 emergency mental health services, it is sometimes the only option for people. People should have the right to mental health supports when and where they need them. We know that mental health problems do not happen from 9 a.m. to 5 p.m. on a Monday to Friday and they can happen anytime. We, therefore, need a mental health service that is accessible and operates on a 24-7 basis for people to get the help they need.

Let us imagine being a person with suicidal thoughts who arrives at an emergency department that is overwhelmed. Does the Minister think that person who presents to the emergency department following self-harm or suicide-related ideation will receive compassionate, empathetic, validating responses, as outlined in the HSE model of care? The reality is much different. In January, Sinn Féin and I published the results of a survey that asked people to share their experiences of mental health, and I sent the Ministers copies of this report. One of the sections in our survey asked about people's experiences of seeking help for mental health difficulties in emergency departments. Almost 60% of people who took part in our survey attended an emergency department to seek support for mental health difficulties, yet 85% of them felt they did not get the support they needed. We have all heard of the tragedies of people presenting to emergency departments desperate for help and not receiving it. It is high time the Government prioritised mental health.

Seán Crowe (Dublin South West, Sinn Fein)
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This week, HSE officials were before the Joint Committee on Health regarding the challenges facing many emergency departments across the State. It was a valuable meeting that served to highlight the damage that failure to invest in hospital capacity, primary and community care and workforce planning has done to our health service. I made the point, and it has been reiterated tonight, that it is frustrating for many people to be told go to their GP. In many cases, people do not have a GP or they cannot get to GP when there is a difficulty. When is the best time to get sick? It is certainly not on a weekend, certainly not at Christmas and certainly not on a long weekend. There are challenges within the system.

I made the point that my big worry is that many people who are seriously ill will not go to an emergency department. I also made the point that many years ago, when I had sepsis, I was not going to go to an emergency department. Fortunately, I was persuaded by my wife to go along and I would not be here today only I did that. I appeal to people, despite all the challenges they are facing in emergency departments, that they need to go if they are feeling sick and they should send a loved one there if that is needed. I can understand if they are immunocompromised, elderly or seriously ill that it is the last place they want to go, but it is the right path for them and their families.

I am old enough to remember that, when the then Taoiseach, Enda Kenny, was making his 2011 election speech, he said we would end the scandal of patients on trolleys. We are further away from that 12 years later.

Pat Buckley (Cork East, Sinn Fein)
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It has been said here tonight that there are 73 patients on trolleys in CUH, with 13 waiting for beds in the Mercy Hospital. What we are facing at the moment is not surprising but it is unprecedented. I am glad the Minister and the Ministers of State are present. The Government is closing a 22-bed mental health respite centre in Midleton, the Owenacurra centre, in the middle of a health crisis. As I raised with one of the Ministers of State in a Topical Issue debate before Christmas, we have excessive deaths in nursing homes, in particular in CareChoice in Ballynoe, east Cork, with no independent inquiry, so there is nothing moving forward there. Last October, there was a pilot project and a feasibility study on ambulance services bringing patients to Mallow General Hospital instead of CUH, and we have seen no progress on that either.

My biggest fear, and the reason the motion was tabled, is that we need to push forward because people are terrified to go to the emergency department. Our front-line workers are probably the best in the world and they are not getting the support they need. The HSE management is top heavy and that has to be addressed. I recall a number of years ago talking to a gentleman who had had a triple heart bypass and he was on a trolley in a hall with no privacy, and that hall was absolutely jammers. That has not changed in seven or eight years. Unfortunately, the Government has normalised an unsafe, undignified and inhumane health service, which is nothing that we should ever be proud of. I appeal to the Government to start to address this immediately. If asses have to be kicked at top level, then kick those asses because patients are dying.

Réada Cronin (Kildare North, Sinn Fein)
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It must be about a year since I saw an exasperated hospital consultant refer to trolley conditions in his emergency department as the warehousing of patients. In the time since, the situation has got even worse. I think I saw him again over Christmas saying the exact same thing.

Before I go any further, I want to thank the hard-working staff at Naas General Hospital who continue to work in overcrowded conditions that are too frequently appalling. They know better than anyone that the dysfunction in the health service is getting wider and deeper, while the way they are treated as workers goes from bad to worse. We have heard it from the non-consultant hospital doctors who are being driven to distraction by the way they are being treated by their employer, the HSE. When I talk to comrades from the North, no matter how bad the NHS is, they talk about it with respect. The people love it and the workers in it love it, but people who work for the HSE have had enough. I will stand with the workers in the HSE in their fight for better and more humane conditions. Let us face it: there is something incredibly selfish about treating the people we depend on to heal us and our loved ones so carelessly and so badly, with no regard for their well-being. That has to change. If enough people decide they want a change of Government, it will change.

Sinn Féin has a multi-annual plan to tackle capacity, be it capacity in beds, diagnostics, surgery, both acute and elective, or medical personnel.

We need change urgently in the HSE. Many of our healthcare workers want to stay and build their careers, have their families and live their lives here, which they would do if they were treated better in their conditions so that they could rent a home at a fair price, depend on public transport and have a decent life without breaking the bank. None of that is looking for too much. All of that is achievable if we put people first, value for public money first and public services first rather than a private, for-profit approach. It is achievable if we had a government thinking in terms of the economy and society, and not just the economy alone.

Despite the Taoiseach's musings that more beds might be bad for how hospitals work, the people out there, including all medical staff, know that is pure nonsense. It is difficult to hear him say that it is not just a question of getting beds in; that they must be staffed. We know that. He should stop treating the people like fools. We need more capacity to take our growing population into account. We need more hospital beds. We need at least 800, be it in acute hospital or community settings, before next winter. We need more doctors and nurses, and all the allied healthcare professionals to make sure that we make the best use of them to get the best health outcomes for people, patients and staff alike. Above all, we need long-term planning and joined-up thinking, and we need to retain the medical staff we have.

Stephen Donnelly (Wicklow, Fianna Fail)
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I move amendment No. 1:

To delete all words after "That Dáil Éireann" and substitute the following:

"recognises that: - this Government has delivered record funding to permanently increase capacity in our health service, with the Health Vote over €24 billion for 2023 up from €14.8 billion in 2018, and this is the largest allocation ever for the Department of Health;

- since 1st January, 2020, 970 new acute hospital beds and 365 community beds have opened;

- 65 additional critical care beds have opened since early 2020, bringing overall capacity to 323 beds, an increase of 25 per cent over the 2020 baseline;

- thanks to successive large increases in the health budget, there are 17,403 more people working in our health service than there were at the beginning of 2020, this is an expansion of 15 per cent, which includes 5,169 nurses and midwives, 2,870 health and social care professionals, and 1,801 doctors and dentists;

- funding has been secured in 2023 to continue this considerable expansion of the workforce with an additional 6,000 staff to be added this year; this growth will be seen across all service areas and in key staff categories, such as medical staff, nurses and health and social care professionals;

- limited access to diagnostics can result in patients being referred into hospital emergency departments (EDs) and outpatient departments for services; the nationwide general practitioner (GP) Access to Diagnostics programme, which began accepting referrals in January 2021, facilitates direct referral by GPs to diagnostic services for their patients; this structured pathway for GPs to directly access diagnostic tests enables a greater level of care to be delivered in the community, supporting patient-centred care, early diagnosis, and early intervention; and 251,601 scans of various modalities were completed by 25th December, 2022, which far exceeded the 2022 target of 195,000 scans;

- the Enhanced Community Care (ECC) programme is a suite of reforms enabling new ways of working, empowering local staff leadership to meet the needs of local communities and a shift in the focus away from acute hospitals; the Government is strongly committed to this goal, and have allocated very significant resources to ensure that this transformation will be delivered, with annual funding of €195 million provisioned to the ECC programme to enable recruitment of 3,500 additional staff, and with service delivery provided through Community Healthcare Networks (CHNs) and Community Intervention Teams (CITs), that commitment will continue into future years; and significant progress is being made, with 91 of the 96 CHNs and 42 of the 60 CITs now established, almost 2,500 staff recruited to the programme, with the balance of recruitment and establishment of the remaining teams targeted for 2023;

- the Government has strongly endorsed all 16 of the recommendations presented in the Report of the Strategic Workforce Advisory Group on Home Carers and Nursing Home Health Care Assistants (October 2022) and is committed to their full implementation as a priority; the Advisory Group's recommendations are targeted measures which, when implemented in conjunction with the wider sectoral reforms which are in train, will have a lasting impact on the workforce challenges associated with front-line care-workers; however, given the breadth and complexity of the issues that affect workforce-planning, it is not feasible to provide a precise timeframe for the implementation of each recommendation;

- on 16th December, 2022, the Government announced the authorisation of 1,000 employment permits for non-European Union (EU)/European Economic Area home-support workers, as recommended by the Advisory Group, this promises to significantly reduce the shortage of home-support workers in Ireland in the immediate future; and

- the Health Service Executive (HSE) procures home support services via a contractual arrangement with providers and it is envisaged a new contract will be finalised by 30th April, 2023, which presents an opportunity for sectoral reform, and the process of finalising the new tender is underway in the HSE and established procurement protocols apply; notes that: - our health service, in common with health systems across the northern hemisphere, is under significant pressure due to a combination of influenza, Covid-19 and respiratory syncytial virus (RSV); and in the United Kingdom (UK) the Health Secretary has said that England is suffering its worst flu season in a decade, and in France, President Emmanuel Macron has outlined his new plan to stop 'endless crisis' in the French healthcare system;

- our population is both growing and ageing, which is welcome but puts additional pressure on the health service, the population has increased by about a third between 2002 and 2022;

- there is a significant increase in presentations to EDs from older patients;

- 194,230 people over 75 years of age attended EDs up to the end of 2022, and that represented an increase of 25,505 (15 per cent) on 2019;

- of these 194,230 some 101,561 people were admitted, an increase of 9,988 (11 per cent) on 2019; and

- significant additional funding was made available to support the HSE's Winter Plan 2022/23, which is supporting delivery of a range of actions to optimise available capacity across community and hospital services by expanding GP access, including within the GP out-of-hours service, facilitating patient flow through the hospital system, and supporting safe and timely discharge to the community upon completion of hospital care;

- building on recent investment across 2021 and 2022, the Department will continue to develop critical care, acute and community capacity, and progress a strong pipeline of capital projects with the HSE, including several new hospitals (including finishing construction of the National Children's Hospital, progress the elective programme/elective hospitals, and relocation of the National Maternity Hospital) and significant new facilities for existing hospitals;

- the Department is also developing a new Strategic Healthcare Capital Investment Framework, including a standardised/streamlined Capital Appraisal Framework for the healthcare sector, refreshing the Health Services Capacity Review, working out a medium-term capital plan to the end of the decade and building the required sectoral capacity, working with the HSE to deliver health infrastructure under the National Development Plan 2021-2030 process;

- the Department of Health is currently engaging closely with all stakeholders in working to mitigate the current immediate medicines shortage issues;

- of the products currently in short supply, there are none that do not have a therapeutic alternative that can be used to meet patient needs;

- the position, as outlined by the Health Products Regulatory Authority (HPRA) last week, remains that alternative strength, brands, and formulation are available for all medicines associated with the current winter surge; HPRA, through the medicines shortages framework, is managing the coordinated stakeholder response to these shortages to minimise patient impact;

- HPRA continues to engage with suppliers to obtain updates and remains open to expediting regulatory procedures to enable supply of additional stock, where possible;

- a subgroup responsible for Antimicrobial Resistance and Infection Control (AMRIC) is meeting with HPRA daily to provide live data to prescribers regarding currently available antibiotics;

- while other countries have introduced Serious Shortages Protocols (SSP) to allow for both generic and therapeutic substitution, Irish legislation already provides for generic substitution of therapeutically appropriate alternatives; the Minister for Health has asked his officials to explore options around developing a protocol to allow for therapeutic substitution in certain circumstances;

- key considerations may include the legislative amendments that would be required (as they were in the UK) to allow for the use of SSPs under Irish legislation, and the framework and governance of such a system; a SSP does not address over-the-counter medicinal products; and in the UK, as in other jurisdictions, SSPs are time-limited and have strict conditions associated with them; and

- there has been an increase of almost 30 per cent in the number of first-year nursing places in Irish Higher Education Institutions over the period 2014-2021 (from 1,570 to 2,032), with an additional increase planned for 2023; and further notes that: - the HSE directly engaged with the Private Hospitals Association (PHA) ahead of the Christmas period and asked that any additional capacity available be identified through HSE Acute Operations; and hospitals and hospital groups were also requested to continue to engage locally in this context;

- the HSE is continuing to engage with the PHA to maximise additional capacity, particularly for medical patients and time sensitive or urgent procedures; a series of local arrangements are in place and there are currently approximately 180 public patients in private hospital beds;

- additional GP supports have been made available to enable GPs to extend existing clinics or run additional clinics during weekday evenings and Saturday mornings; the funding grant arrangement for GP out-of-hours cooperatives has been increased by 7.5 per cent and additional funding is being provided to cooperatives to enable them to roster additional doctors, local GPs and locum doctors in treatment centres from 6pm to 10pm;

- these measures allow more patients to be seen by GPs and out-of-hours cooperatives, helping reduce need for ED attendance;

- this Government is committed to achieving one of the core goals of Sláintecare by continuing to invest in reforming and re-organising health and social care services, so that they are expanded and focused on delivering care in the community with a 'home first' approach;

- a number of teams currently operate in the community to provide care for patients at risk of hospitalisation or to facilitate discharge from hospital, for example, referrals to CITs have consistently performed above their annual targets and since October, referrals to the CITs have increased month on month; significant investment in recent years has facilitated an increase in the number of CITs from five in 2014 to the 21 CITs currently in place, ensuring national coverage for the first time and with at least one team in operation per Community Healthcare Organisation area; and we continue to augment and expand this invaluable service, with Winter Plan funding having been provided to target recruitment of additional staff to the CITs;

- the mandate of the European Medicines Agency (EMA) was formally expanded last year by way of Regulation 123 of 2022, which expanded the remit of the EMA to enhance its response to and coordination of shortages of medicines and medical devices at a European level, with a particular focus on driving consistency of approach with respect to mitigation actions; and

- the EMA is liaising with antibiotics manufacturers with a view to increasing supply to the EU market; and the HPRA is taking a lead role in this EMA work on behalf of Ireland.

I very much welcome the opportunity to talk about the issues raised concerning capacity in the healthcare system, and one element and knock-on effect of that, which is the unacceptable levels of overcrowding we are seeing in some hospitals in the public health service.

The context matters. The motion does not reference the context at all. Ireland and Europe are dealing with a perfect storm of Covid, RSV and flu. We are dealing with an unprecedented level of the combination of all three of those. The best resourced and run healthcare systems in Europe are dealing with various versions of what we are dealing with in Ireland. That context is important. This is happening throughout Europe. Deputies will be aware of the situation in the Six Counties, which is very serious indeed, as it is in Britain as well.

However, we must focus on our health system and do everything that we can. I have visited emergency departments around the country. I wanted to hear first-hand from patients and their families, and healthcare workers about their experience. I have seen the distress. I have spoken with patients and their families and with healthcare workers about the distress in many of our emergency departments. I acknowledge that what I have seen and what patients have experienced in many hospitals around this country in recent weeks is simply not acceptable in terms of the time waiting to be treated and the time waiting to be admitted to a bed in a hospital, if a decision is made to admit.

I have also visited hospitals where patients are being seen quickly. They are being treated quickly and they are being sent home quickly, or if they are admitted into the hospital, they get a bed quickly. In Waterford, Deputy Cullinane's constituency, the hospital has gone more than three years without having a patient on a trolley. We must be cognisant of those hospitals and those parts of the country where things are clearly working very well.

The motion tabled by Sinn Féin calls for an urgent expansion in the capacity of our public health service – more beds, clinicians and home care packages. What the motion fails to acknowledge in any way is that we are in the middle of an unprecedented expansion in capacity in the public health service. Over the past three years we have added nearly 1,000 hospital beds, more than 360 community beds and there has been a 25% increase in critical care beds. This is an unprecedented expansion in public beds across the country.

We have hired more than 17,000 additional healthcare professionals since 2020. This includes more than 5,000 nurses and midwives, nearly 3,000 additional health and social care professionals, and 1,800 doctors and dentists. In fact, 2020, 2021 and 2022 are three record years of net recruitment into the HSE since its foundation. This year is going to be the fourth in a row. The past four years, including this year, will have had the highest recruitment into the HSE ever. Do I want to go further and faster, and does everybody here want to do the same? Yes, but let us acknowledge that in the middle of Covid, the HSE has hired at a level that has never before been seen.

Our emergency departments depend on highly skilled and experienced staff to provide patients with care. We are rapidly expanding resources within emergency departments. I sanctioned 51 extra emergency medicine consultants last year. That is approximately a 40% increase in the total number. We have launched phase 2 of the safe staffing framework, which increases the number of nurses and healthcare assistants in emergency departments. However, as we all know, no additional resource we can put into emergency departments will solve the issue of overcrowding on its own. What we all know is that most of the solutions to the overcrowding in emergency departments lie outside them. That is why we are continuing to invest right across the board so that only those who really need hospital care come to the emergency department and when they do, they get seen quickly. We have added millions of extra hours of home care support. We fully acknowledge that more is needed.

The motion calls for a move to the living wage in the new tender. That is happening. We are also recognising travel. We have also added 1,000 work permits. The Minister of State, Deputy Butler, is leading the work on this for the Government. She and I would like to see that go much further. We acknowledge that too many people are waiting for home care packages. The funding is in place, and we are taking action to increase the workforce to be able to help those patients and their families.

We are also investing at an unprecedented level in the expansion of primary care, as called for in Sláintecare. Over approximately an 18-month period, we have put more than 90 new primary care teams in place. There are many new specialist teams throughout the country in elderly care chronic disease management. Approximately 2,500 healthcare professionals have been hired into this new enhanced community care programme around the country in every one of our constituencies over the past 18 months. This year we will continue with that. These teams, which are quite new, will further integrate into the healthcare services. They will integrate with GPs and into the nursing home sector, as well as the hospital sector. More and more patients can be treated at home and supported at home; treated in their primary care centres and community so they do not need to come into hospital, or if they do, they can be discharged as quickly as possible.

We all know that limited access to diagnostics is one of the reasons people end up in emergency departments. The GP access to diagnostics programme, which was launched in 2021, has been a great success. This year, we have allocated tens of millions of euro. It means that GPs around the country can directly refer their patients for diagnostics. Last year, more than 250,000 scans were funded and took place under that programme, which is new. Sinn Féin is calling for more diagnostics. I accept that more is needed, but what Sinn Féin is not acknowledging is that it is happening.

The motion calls for an increase in training places for clinicians; I agree. However, the motion fails to recognise that an increase in training places is happening. More training places are being funded for students and for clinicians pursing advanced practice, such as non-consultant hospital doctors, NCHDs, who are seeking to become consultants. I have stated previously that we need to double the number of college places in healthcare in this country. They are increasing in several areas, but we need to go further. The Minister for Further and Higher Education, Research, Innovation and Science, Deputy Harris, and myself are working together to that end. I have met several of the medical, healthcare and nursing colleges to see if there is an appetite for a radical expansion in courses for nursing, midwifery, dentistry, pharmacy and health and social care professions. The answer from every university team to which I have spoken is that there is. They want to work together to expand these places. We do not train enough healthcare professionals in this country.

In spite of what is an unprecedented expansion of capacity – beds, diagnostics, workforce community care – we are all aware that a perfect storm of Covid, flu and RSV, coupled with a growing and ageing population, means that too many men, women and children are not getting seen quickly enough in emergency departments or getting a bed in a hospital quickly enough when they have been admitted. They are also not getting access quickly enough to other healthcare services they need. What are we doing? We are continuing with the expansion. This year, we are funding an additional 6,000 healthcare professionals across the service. Hundreds more beds are planned for this year. Building on recent developments, my Department is working with the HSE on the roll-out of new elective hospitals, the rebuilding of the national maternity hospital and finishing the national children's hospital.

However, as I said previously, the current capital processes in this country, be they in the HSE, the Government, or are tendering and planning processes, when they are considered together, are not working. It takes years and years to put in place capital infrastructure and critical healthcare infrastructure that we need to put in place much quicker. I am working with the Department, the Government and the HSE to see what actions we can take to significantly reduce the amount of time required from when a decision is taken to add beds to those beds being open, staffed and used to treat patients. The current combination of processes, between European laws, tendering laws, planning processes, internal evaluations, re-evaluations, strategic reviews, business case modelling, and external validation of strategic reviews, when put altogether, are taking years and years to put critical infrastructure in place that patients need now. That is something we are looking to change.

At the same time, more capacity is not the only answer. There are significant changes to working practices and more community-based care is not the answer in and of itself. We also know there are significantly different outcomes from different hospitals and community groups throughout the country. We must see consistency of good practice. We have to see more hours in hospitals and the community sector whereby senior decision makers are present to treat, admit and discharge patients and help to bring them home. It is what the new consultant contract is all about. Over the past few weekends, we have seen the enormous beneficial impact of having senior decision makers in hospitals and the community at weekends.

We need more capacity. We are in the middle of the biggest expansion in capacity in a very long time right across the system. At the same time, we need to implement the Sláintecare vision of community-based and integrated healthcare. That is happening. In addition, we must modernise working practices, patient flow, treatment and discharge, and rostering, right across our service. If we do and continue doing all those things - we are in the middle of doing all those things although a lot more is needed - we will see a well-resourced, well-staffed and well-funded modern healthcare service that gets people throughout this country the care they need when they need it.

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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I thought the Minister was in the Opposition for a few minutes because he outlined all the things that need to be done. However, the fact of the matter is a large portion of his Government has been in power since 2011 and all the current failings have been there since then.

I received an email recently from a constituent, Elaine, regarding her six-year-old son who fell ill and had to go to Caredoc in Sligo. Caredoc has its own problems. She waited several hours before her son was seen there. Finally, it was recognised that he needed to go to the emergency department. He was sent there and waited from 6 p.m. until 11.30 p.m. to get an operation to treat a perforated appendix. The one surgeon on call had to hunt up and down through the hospital to get a surgical team together in order to carry out that operation. The family have said how grateful they are for that surgeon and his efforts because that saved the child's life. His mother says in her email that this begs the question as to what would have happened if they had been unable to gather a team or if the one surgeon on call was already in surgery with another patient.

Stephen Donnelly (Wicklow, Fianna Fail)
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What hospital was this?

Martin Kenny (Sligo-Leitrim, Sinn Fein)
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That was Sligo University Hospital. It is the same in any hospital throughout the country. The situation is dire in so many of our hospitals around the country. I accept that the Minister can come to the Chamber and tell us about all the great work that is happening. He is in the middle of everything but nothing seems to be concluded. Certainly, in the experience of the people dealing with the health service, they do not see the results. That is the problem we have got. We really need to sort this situation out.

I will return to the matter of Caredoc, which is the out-of-hours service in the north west that deals with counties Donegal and Leitrim. We have a serious situation with NoWDOC where, at present, it is worked between Caredoc and the HSE. It is now proposed that Caredoc will take over NoWDOC entirely and the HSE will withdraw from it. This is a process I see all over the country. It seems to be the case that the HSE wants to do no work itself but wants to privatise it all. It wants to bring private companies in to run everything. I received an email from a staff member there, which states she is very concerned about the selling out to the private contractor Caredoc, where the only reasons for taking over this service will be to make profit. There is no doubt in her mind that corners will be cut, that there will be no nurse presence in Carrick-on-Shannon and eventually, once established and under the radar, they will stop doing home visits and move the service centre out of Carrick-on-Shannon to Sligo. This is the real fear an awful lot of the staff working in this service have. They see this happening under their very noses. When we write to or contact the HSE, we are told there is nothing really to talk about here, and these are private negotiations it is having with a private provider, which has nothing to do with the public. It certainly has an awful lot to do with the public when they cannot get a service and when the service is being withdrawn from them.

Pa Daly (Kerry, Sinn Fein)
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Most of the staff in University Hospital Kerry are too busy dealing with a hospital that was built in 1984 to serve 120,000 people, when County Kerry now has a population of 160,000, to be out campaigning. There were glad when a review of the hospital was promised. A team visited the hospital and staff there were told a transformation team was needed. A review and interviews were carried out but in the past ten days or so, staff were told that that review has been shelved.

Staff are back to square one. I will give two examples. Oncology services in Kerry hospital include cancer patients and some of the most vulnerable people. Those with black humour are calling the oncology unit the homeless unit because, in the middle of the Covid pandemic, that unit was sent to palliative care. There was then a plan. Somebody thought it would be a great idea to spend €2 million to place the oncology unit in a private hospital, while that private hospital would invest a fraction of that amount. Thankfully, that idea was shelved but it is worrying that it was seriously considered. After palliative care, the unit is now being moved to the day ward. Oncology patients are on the day ward so surgeries for day patients have been cancelled and not one surgery has been carried out this year. Some 20 operations have been cancelled. The unit will probably be closed. If the last surgery is anything to go by, the day unit will probably be closed for months.

The stakes in healthcare services have never been higher. There have been decades of neglect in respect of staffing and infrastructure. We accept that cannot be fixed overnight but one person told me that hospital staff in Kerry are under nearly as much pressure as they were during Covid and there is no sign of improvements. The Irish Nurses and Midwives Organisation, INMO, recently reported that 20 patients were on trolleys in University Hospital Kerry. Last December, 36 patients had been waiting more than six months for inpatient procedures and 476 outpatients were waiting for the same time period. For a county the size of Kerry, these are extraordinary numbers.

With an ageing and rural population, in a county with high peripherality and three peninsulas, the solutions for Kerry are obvious. Beds mean staff who must be trained. Retention and training need to be prioritised. That includes other areas. There are ways to ease the pressure. There must be more public involvement in community hospital step-down facilities and 70 or so beds.

Imelda Munster (Louth, Sinn Fein)
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In 2006, hospital overcrowding was declared a national crisis. Declarations were made by the then Fianna Fáil-led Government. Each Fianna Fáil- and Fine Gael-led Government since then swore that this would be resolved. Despite that declaration, and all the statements on resolving hospital overcrowding from Fianna Fáil and Fine Gael health Ministers, and Fianna Fáil-led Governments, 17 years on we are looking at what could be considered a bad, repetitive joke, if it was not so serious. It is like Groundhog Day. It is winter. There is overcrowding in our hospitals. The Government continuously ignores warnings and pleas from front-line health professionals who are worked to the bone, stressed to the hilt and whose morale is on the floor. In December alone, nearly 12,000 patients were admitted to hospital without a bed. We have had 17 years of Fianna Fáil- and Fine Gael-led Governments.

At the start of December, 11 ambulances were parked outside my local hospital, Our Lady of Lourdes Hospital, Drogheda. The patients could not be taken out of the ambulances. They had to sit inside them as the ambulances could not go anywhere because there were no beds or trolleys. It is 2023 in a First World country. It is nothing short of outrageous. That overcrowding will get much worse if the Government continues to ignore the health professionals in Our Lady of Lourdes Hospital, Drogheda, and moves all the acute emergency cases from Our Lady's Hospital in Navan to Drogheda. Again, it is as if the Government is not listening. I genuinely believe, and I am not being political, that the Minister is afraid to take on the HSE.

He is afraid to take it to task. Other Members here tonight have thanked the front-line staff. I will thank the front-line staff in Our Lady of Lourdes Hospital and right across the State for the Trojan work they do in spite of their desperate working conditions and the fact that the delivery of every single type of public health service and support is crumbling under the Minister's watch. There is a shortage of GPs, there are no dentists for medical card patients and hospital appointment waiting lists are out of control. There is also a shortage of home care supports, a lack of funding for housing adaptations for elderly people who are being discharged and a dire lack of mental health service provision and supports. There are no beds and no trolleys. The list goes on and on after 17 years of Fianna Fáil and Fine Gael. Sinn Féin will deliver the public health service that the people need and deserve.

Johnny Mythen (Wexford, Sinn Fein)
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Our healthcare service is broken and not fit for purpose. It has been broken for a long time. The provision of a fully functioning healthcare service that can look after people and its staff should be a duty of care and priority for any Government worth its salt. The Government has utterly failed in this measure. The Minister referred to the years 2021 and 2022. The Irish Nurses and Midwives Organisation, INMO, only reported five days on which there were fewer than 350 patients on trolleys in 2022 and no days when there were fewer than 300. It is the ordinary people, those who cannot afford private healthcare, their families and friends and our healthcare staff who are suffering, with damning consequences.

The situation is no different in my county, Wexford, despite the personal sacrifices, double shifts and sheer determination of the healthcare staff there. We have seen recent reports of ambulances queueing for hours, with patients being treated in the back of their vehicles causing further delays, sometimes with devastating results, including even death, as ambulances are held up for hours. As I speak, the INMO is reporting 14 people on trolleys in Wexford General Hospital. Do we ever stop to think that our nurses should never have to conduct a trolley watch in the first place? This should not exist in a system that is well run. The announcement of a new 96-bed unit for Wexford General Hospital made for great press releases for local Government representatives but where is it? Will the HSE be able to recruit the staff needed to operate it? The serious recruitment and retention crisis in healthcare casts a significant shadow of doubt yet I see no proactive strategic plan to really tackle this head on. We cannot treat people's broken limbs with broken promises.

The real question is whether the public has confidence in the ability of this Government to fix these issues. Taking into account the evidence of statistics over the last decade, we see that the answer is "No". Sinn Féin has credible alternative policies, which have been brought through by Deputy Cullinane, our spokesperson on health, to solve the crisis in healthcare, and which we have constantly outlined. Our people cannot wait one more day. Change is needed now.

Seán Sherlock (Cork East, Labour)
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I welcome the motion, which we support. I also acknowledge the bona fides of the Ministers opposite in trying to fix a perennial problem. I read the Minister's speech carefully but feel that there is much more that can be done to increase capacity.

The Minister refers to the investment in diagnostics and primary care in particular. It is all well and good to state that the HSE has added 90 additional primary care teams in the country but there is still an issue in that people in the constituency I represent cannot get to the GP in the first instance. The diagnostic piece does not, therefore, arise. I am told by my constituents in the town of Mitchelstown, where we have an excellent primary care centre, that they are waiting up to two or three weeks - four weeks in one instance - to see or interact with a GP in a primary care centre. I am not here to criticise GPs. They are absolutely snowed under. We know that. However, with all due respect to the Minister, until such time as people can get access to the GP in the first instance, the issue of diagnostics is moot. I need to know how we are going to fix that. That is the problem that I need to see fixed. We know what the latent effect of people not getting access to basic GP services in the first instance is. It just heaps up a pile of problems for the long term. If there is no access to diagnostics, it just shores up a pile of problems down the line. I need answers to the questions I have in respect of Mitchelstown. The situation is similar in Mallow. It is not just Mitchelstown and Mallow, but every town in the country. Why is it that people now have to wait so long to get access to the GP? I do not blame GPs. We are very quick to blame. We need to blame somebody for problems. However, where is the solution to those problems?

As a local Deputy, I, for one, have done a lot of work with some of the GP practices in my area to try to assist them with visas for GPs coming in from third countries or from outside the European Union. We have had some measure of success there. Many people are now emigrating and taking up job opportunities elsewhere. If the Government and the HSE were to take a proactive approach to recruiting from across the globe - there is precedent for this and it is being done day in and day out - we could bring in GPs from other countries, which would help alleviate the problems in places like Mitchelstown and Mallow. That is one possible solution.

With regard to out-of-hours services, throughout the Christmas period, we all received calls from people who could not get access to services such as that in my area, SouthDoc. SouthDoc is an excellent service. Once you get in the door and are seen, it is the best service in the world but there is the question of getting that initial access. I know of some very acute cases that arose over the Christmas period in particular. I do not have a degree in medicine and am not qualified to diagnose but, if I am contacted by an anxious parent who is seeking access to the service for a three-year-old, who has been waiting six, seven, eight, nine or ten hours for a call back from the out-of-hours service and who does not want to go to the emergency department because they are petrified of going to Cork University Hospital, CUH, we have a serious structural problem. Is that also about the supply of GPs? Can we get more GPs? The Minister will say that SouthDoc, Westdoc or the service in whatever part of the country one might be from operates on a co-operative basis but the HSE and the taxpayer are also big funders of these services. We have skin in the game and, as such, I am sure that we have influence at a ministerial level over how these services operate. All I want for my constituents is access to a GP when they need it because, once someone gets in the door of a primary care centre and gets access to a GP, a lot of triage can be done, reducing the need for people to present to the accident and emergency department in CUH.

Do not get me started on CUH. I was there with somebody recently and saw the ambulances backed up and the lack of beds. That is again a structural problem but it did not just arise because of RSV or Covid because the trolley numbers are now up in the months of June and July as well. There is evidence for that. It is a year-round thing. When you look at the faces of healthcare professionals, which the Minister has seen, including nurses, doctors, attendants and people working on the floors, you see that they are all stressed out to the hilt. That is not sustainable. I genuinely worry for the health of our healthcare professionals at the moment. I genuinely worry that many of them are now saying they have had enough, they cannot take any more and they are out. It is hard to blame them. We need to try to alleviate the pressure.

There is another way of alleviating the pressure. Level 2 hospitals are an untapped resource. Take Mallow General Hospital for example. The Minister spoke to issues around capital expenditure and turning bricks and mortar into wards. We have a 42-bed unit in Mallow General Hospital that is all but built.

The hospital is operating excellently. It provides a great deal of elective care for people. It is excellent in diagnostics. Many people could be triaged on an out-of-hours basis and directed into hospitals like Mallow General Hospital. I ask the Minister to fast-track the 42-bed unit. We would get it up and running for the Minister. We would take people out of Cork University Hospital, CUH, and move them into Mallow General Hospital, as well as places like Ennis and Nenagh hospitals and other hospitals. The excellent staff on the ground will do what the Minister has spoken about in terms of delivering the healthcare we need. That would alleviate the pressure on CUH and this can be done now. The bricks and mortar are there. I invite the Minister to visit Mallow to take a look at it for himself. It is an excellent hospital.

The writing was on the wall for the accident and emergency department a long time ago. We did a lot of work in respect of building out endoscopy suites, medical assessment units, a local injuries unit, an urgent care centre, etc. We now have a 42-bed unit and if the Minister will give us the money to put beds into it, we will do the business for him. That is what we want to do in Mallow. This would take a great deal of pressure, from a regional perspective, off tertiary care centres like CUH. It will not only serve the people of Mallow but also those in Tipperary, Limerick, Waterford and the whole catchment area. If we look at Mallow on the map, we will see it is right in the heart of Munster. This is what we are talking about in terms of solutions. The Minister has the capability, wherewithal and means to do this because he is the Minister. If he could take a look at Mallow General Hospital specifically, we could do a job of work there.

We also need to talk about ambulance care. We are all deeply worried about people who work in the ambulance services. They are stressed out as well. They are being asked to do double shifts and take on extra work. I fear for their health and safety. In the not-too-distant past, we had a case where somebody going home from doing a shift crashed because they were just absolutely wrecked tired, to use my local parlance and to speak in the vernacular. We just cannot have that. People need to have adequate rest between shifts. We cannot have a situation where we are trying to squeeze more and more hours of healthcare professionals because at some stage it becomes dangerous for them and the people they are treating. I ask the Minister to take a look at this aspect.

In the few seconds I have left, I will speak about pharmacies, which are yet another untapped resource. Community pharmacies have tremendous capacity to deliver, if they could be built out to deliver more at the community level. If I am not mistaken, the Minister may be doing some work in this area already. I ask him to fast-track that. Pharmacists are excellent. They provide excellent advice to people in their communities daily and they could do much more if they were given the training and resources. Increased capacity will require resources. I think the Minister is saying there is a budget of €23 billion. What we are seeking for the few small things I have mentioned would not be big money at all. The Minister could do it.

Róisín Shortall (Dublin North West, Social Democrats)
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To pick up on the last point made by Deputy Sherlock, there is an excellent example of what a community pharmacy can do in Cloyne. I am very familiar with it. That is a model that should be replicated all over.

I very much welcome this motion. It is timely given the horrendous few weeks we have come through. At this point, after the last two or three weeks, some of the measures taken have kicked in and they have been relatively successful insofar as the indefensible figure of 930 people being on trolleys has been reduced to a somewhat more manageable but still unacceptable figure of more than 500. Actions were taken that were effective. I completely agree with the Minister in respect of people coming in over the weekends and ensuring there was patient flow and all that kind of thing, which is so important. This is obviously what we should be aiming for. Doing it with a reduced staff capacity and a reduced number of beds, however, is not sustainable in any kind of long-term way. The additional hours people worked on top of their normal week, the extra overtime and all of that was very effective and showed us what can be done if we have sufficient staff. Fair dues to the people who did that but, as I said, this cannot continue because people are already wrecked after the last two years. A big effort was put in and we did get rewards from it.

We must stop staggering from crisis to crisis. The Minister knows the definition of madness is when we keep doing the same thing and expect to get different results. This seems to be what has been happening winter after winter, except that the crisis that used to exist during winter now rears its head several times during the year. There is, therefore, much to be done. Many good suggestions have been made in this debate and lots of people have ideas. The key point is the implementation of these ideas because we cannot again find ourselves in a situation like the one we were in over Christmas. The Minister must accept that is utterly unacceptable. It must also be accepted that it was, in large part, entirely predictable. Last September, for example, Fergal Hickey told the Minister that we were facing Armageddon. He predicted that winter was going to be disastrous, yet plans did not seem to be put in place to cater for that. We knew that Covid-19 was going to spike again and also that the flu was going to be a major factor.

What is to happen? I accept what the Minister said. There have been additional beds, but they are not enough. There have also been some additional staff, though not enough. I will return to the point on staff in a moment. The most urgent issue that needs to be dealt with is the manner in which we run the health service and the manner in which the HSE operates. It is very easy for people to criticise the HSE and a predecessor of the Minister had plans to abolish it. All that kind of talk is nonsense. The HSE is our health service. What we must do is reform it. There are major problems with the way it functions. It is quite a dysfunctional organisation. It is highly centralised. It is a command-and-control organisation and hierarchical. When something goes wrong, whether in south Kerry, north-west Donegal or wherever, the CEO comes on the airwaves apologising and promising us a report. We cannot function like that. It disempowers managers down the line and means that managers become administrators. We pay a lot of managers and we should expect them to manage. This means placing responsibility on them and them then being responsible for spending budgets. It means ensuring those budgets are properly spent, we get value for money and services are managed so that they are adequate. We must stop talking about it being great that we are throwing money at the health services. I heard a Minister of State use this phrase last week on television. She said we are throwing money at the health service. We are spending a huge amount of money but we should not be "throwing" money at it. We need to be directing money to where it is most needed. Most of all, we need to reform the way the system operates.

The plan is there for the reform of the HSE, as the Minister well knows. It is the regional health authorities, RHAs. The Sláintecare plan came up with that as the key element six years ago. The Minister of State, Deputy Naughton, was involved in that cross-party proposal and yet progress on that specific aspect has been exceptionally slow. We are looking at this element in considerable detail on an ongoing basis in the Joint Committee on Health. In October last, the chair of the advisory group to the RHAs, Leo Kearns, appeared before the committee. He stressed the importance of devolved authority to allow each RHA to exercise effective decision-making. The guiding principle that should underpin this restructuring is that of subsidiary.

7 o’clock

Authority for decision-making is devolved, responsibility is devolved, people are empowered to manage the service, and that must be underpinned with legal accountability. That is how we get the best out of people. Responsibility lies with senior people in the region.

We know what has happened and the memorandum that was brought to Cabinet last year on that. I am not sure where that originated but all of the evidence would suggest that, at a senior level within the Department of Health and in the HSE, there was serious institutional resistance to the breaking-up or restructuring of the HSE. We know that two very senior and effective people, Ms Laura Magahy and Professor Tom Keane, walked away, unfortunately, because they said the Government is not serious about this. Given the fact there are undoubtedly obstacles and there is institutional resistance at the top of both of those organisations, I repeat, and I have said this a number of times, that it was a mistake to put the heads of those two organisations in charge of implementing something which might discommode them, which they may be uncomfortable with and which they may not necessarily want to see happening.

We are in this situation. The Minister has to listen carefully to Mr. Leo Kearns, who does not pull his punches. He is involved with an experienced group of people in the advisory body.

Stephen Donnelly (Wicklow, Fianna Fail)
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I appointed him.

Róisín Shortall (Dublin North West, Social Democrats)
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I know the Minister did, but the Minister has to listen to him.

Stephen Donnelly (Wicklow, Fianna Fail)
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I am listening to him.

Róisín Shortall (Dublin North West, Social Democrats)
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The Minister has to listen to him and follow the advice he has given. In the view of the committee, that is sound advice. People were very taken, when Mr. Kearns came in, and said this is such a breath of fresh air and makes sense and asked why we are not doing this quickly. That is where things have to go, and quickly.

On the memorandum that went to Cabinet on this, the decision of Cabinet was flawed. The three options in that memorandum were, basically, do nothing, do a little bit, or do the job properly. Unfortunately, the Cabinet opted for do a little bit, and that will not cut it. If the Minister is to do this, he must do it properly. The Minister would have the entire backing of the Oireachtas Joint Committee on Health if he goes back to Cabinet and states we need to strengthen this because it will not work unless it has legislative underpinning, specifically in accountability.

The other key issue is to implement all the recommendations of the Minister of State, Deputy Butler's expert group. It is such low-hanging fruit to tackle the delayed discharges and yet there have been incredible delays in tackling that issue. We talk about extra beds etc. We need extra beds but there are 600 beds that are inappropriately used. When will we see the recommendations of the Minister of State's report implemented in full?

A key part of that is to implement the recommendation on the living wage. That is how we get more people to sign up to be carers. According to a number of people who have examined this area in detail from an academic point of view, it also would help greatly to attract more male carers to come into the system. We cannot delay any longer. We need to see all of those recommendations put in place within the next few months. It is not sustainable to continue with 600 in delayed discharges. While a number of those have been moved, they would fill up again quickly.

Mary Butler (Waterford, Fianna Fail)
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I will speak to that in closing.

Róisín Shortall (Dublin North West, Social Democrats)
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Good. I thank the Minister of State.

Paul Murphy (Dublin South West, RISE)
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I am sharing time with Deputy Barry. It is important to say the health crisis we have, the trolley crisis we have annually, is not a natural disaster. It is not a natural function of winter. It is a policy-made disaster that we get regularly. Those polices are a commitment to a two-tier fragmented health service with a chronic lack of capacity and staffing in emergency departments, acute and elective hospital services, ICU, public health teams, primary care and GP services, mental health and disability services, step-down nursing home places, home care and more. It is a commitment to continuing a for-profit part of our health service, and the for-profit part of our health service only exists if there are problems with the not-for-profit parts of our health service. Finally, this year, on top of those annual problems, we have an extra problem in terms of policy to do with Covid where the Government did not take seriously enough the continuing threat of Covid, on top of which are the flu and the respiratory syncytial virus, RSV. There is nowhere near enough of an effort in terms of promoting the use of masks. We should be listening to the likes of the Irish Nurses and Midwives Organisation, INMO, and the unions representing bus drivers. There is still no action in terms of ventilation and filtration in our public buildings. Earlier I saw a picture from Davos where a number of world leaders were having a conversation. They had HEPA filters in front of them because they work and have an impact. The lack of action in this regard in this country has added to the crisis. It is policy driven. It does not have to be this way.

In the conversations that happen around the regular health crisis, there is often an attempt to obfuscate and to present the whole thing as more complex than it really is and beyond anyone's understanding, as if we keep giving money to this thing and it still does not seem to work in order to make people think there is nothing that can possibly be done about it. Of course, there are complex parts to it and structural issues, but at the basis of the health crisis we have that particularly expresses itself every winter is a basic issue around capacity in terms of beds and staff to go with those beds. Where, in the early 1980s, Ireland had 17,500 hospital beds in our health system, today bed capacity is just over 11,000. It is the same as it was in 2009, when the population was half a million people lower than it is today. That is at the core of the crisis. That is the most important fact that explains why we have the crisis we have. In comparing the number of hospital beds per 1,000 of population in this country, at 2.9, to the EU average of 5.3, we are at little more than half the EU average. An extra 5,000 hospital beds are urgently needed in the public health system to address this core capacity problem.

The other side of this is the enormous profits that are made in private healthcare in this country. Vast amounts of public money are being drained off into the private sector, which also benefits from significant tax subsidies. Three weeks ago, Mr. Larry Goodman's Blackrock Clinic reported a doubling of profits, to €14.5 million, on revenues of just under €160 million. This profiting from our health crisis must stop. We should stop having a public health service that is underfunded and under-resourced and allows the private health system to operate, and the private hospitals should be absorbed into the public system to contribute to the extra capacity we need. We need to take these into the public health system. We need to build an all-island national health service.

I want to say a couple of sentences on the possibility of industrial action by the INMO representing nurses and midwives. They, together with the patients in the hospitals, are really on the front line of the crisis that is of the Government's making. Every year, they are the ones who come out with the trolley watch figures. They are the ones who put this on the political agenda and put real pressure on the Government. Every year, we get the commitments saying action will be taken and this will stop, yet it happens year after year and it is now worse than ever. Nurses and midwives have been left with no choice but to take action.

We can see from Britain that strike action by nurses has put serious pressure on a hard-nosed Tory Government to negotiate. Industrial action by nurses and midwives here would be enormously popular. I was on a television programme where people were asked to text in, and more than 80% of people said they would support strike action by nurses and midwives. This would have the impact of galvanising public support for a mass campaign to force the Government to invest properly in our health service in order to protect patients' lives and the working conditions of all those who are in it.

Mick Barry (Cork North Central, Solidarity)
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The INMO is consulting its membership on the issue of industrial action in support of staffing levels that would be underpinned by legislation. Should the nurses decide to take action they will deserve the support of every health service worker, patient and relative who has had a loved one in a hospital and everyone who either looked on in horror or shook their head in sadness at the shocking overcrowding in our emergency departments over the new year. I have no faith in the Government to solve this crisis. I have no faith in the HSE to solve it. Only workers' action and other forms of pressure from below will achieve the changes we need to see, namely, more beds, more staff, better pay and a real properly funded national health service.

There were 170 patients in the emergency department of University Hospital Limerick on 2 January when a major incident alert in the context of overcrowding and patient safety was triggered. The cap on the number of patients in the emergency department, as agreed by the hospital with the local fire department, is 78. There were more than double that number in the emergency department on the day in question. How many other emergency departments are in breach of fire safety regulations as a result of the failure of successive conservative Governments here to resolve emergency department overcrowding? There was a fire in the emergency department at Cork University Hospital a week ago. Thankfully, it was put out relatively rapidly by a quick-thinking paramedic. How long will it take before a fire tragedy might take place in an emergency department somewhere in the State? This is an issue that needs to be taken very seriously. We should take the events at University Hospital Limerick and Cork University Hospital as a very serious warning signal on this issue.

Peadar Tóibín (Meath West, Aontú)
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On Saturday, there will be a national day of action against accident and emergency department overcrowding throughout the country. For the first time in the history of the State, hospital campaigns throughout the country will work together and will show up in numbers outside hospitals throughout the State. A total of 15 hospital campaigns will be involved in the national day of action against hospital overcrowding. An incredible feat is being undertaken. There are leaflets and posters, and mobilisation is happening throughout the country. At 1 p.m. on Saturday citizens will gather outside Our Lady's Hospital in Navan, Cork University Hospital, Kerry University Hospital, Galway University Hospital, Mayo General Hospital, Sligo University Hospital, Letterkenny University Hospital, Causeway Hospital in Coleraine, Daisy Hill Hospital in Newry, Monaghan General Hospital, Cavan General Hospital, Regional Hospital Mullingar, Our Lady of Lourdes Hospital in Drogheda, Connolly Hospital Blanchardstown, Naas General Hospital and Wexford General Hospital. The protesters in the mid-west representing Ennis, Nenagh and Limerick will gather at 11 a.m. outside City Hall on Merchant's Quay.

In some areas, thousands of people will protest, in other areas hundreds will gather and in other areas dozens will stand. They will stand united on one main point, which is that some day every one of us will depend on a functioning hospital service being there when we need it. The truth is that this is not the case. It is increasingly not the case throughout the country. The old, the infirm and the sick have been most exposed by the current Government and those that preceded it regarding the lack of treatment. It is a form of cruelty that three of the most vulnerable cohorts in our society can be left so exposed every year in the context of the hospital overcrowding crisis. I thank the hospital campaigns for the work they have put into mobilisation. I urge people throughout the country to come out in numbers to their local hospital. I also urge political parties and Independent Members in the Chamber to make sure that they attend the rallies throughout the country and that they mobilise their members to do so. In many places unions, football clubs and civic society groups are mobilising people to get out on Saturday. It is incredible.

I want to focus on a number of issues. Last year, 120,000 people spent time on trolleys. In many cases, the old and sick were left for an average of 24 hours waiting to see a doctor in an emergency department. Overcrowding in 2021 caused 105,000 adverse incidents. In each of the incidents an individual citizen of this country was damaged by the HSE. This is what constitutes an adverse incident. In a number of cases, people were disabled or died as a result of these accidents or mistreatments.

In the five years up to this year, according to the reply I received to a parliamentary question, the State spent €2 billion on compensating people who have been damaged by our health service. This is incredible. Imagine if that €2 billion was focused on the front-line services in hospitals. Imagine the pain and suffering that would have been alleviated in terms of the families who went through these difficulties in hospitals. It is incredible that such a level of damage is being done. In the main, this damage is happening because staff throughout the country are under tremendous pressure. They are under so much pressure that they cannot do their jobs in as proper a manner as they would wish. One of the Minister's predecessors, Deputy Harris, wrote a report that showed there was a direct correlation between understaffing in hospitals and mortality and morbidity. This is what we have in the State.

All of this has not happened by accident. That is the God's honest truth. Over Christmas, I listened to Government Deputies and Ministers going on radio and television to say this level of overcrowding is happening because of RSV, Covid and flu. Are we really saying the hospital overcrowding crisis is happening because people are getting sick? Are we really saying that if the pesky citizens were not getting sick, the hospitals would be fine? Surely we should be designing a hospital service that has the capacity to deal with the illness that exists in society. This is incredible.

There are a number of reasons the health service is in such bad shape. In reality, it was designed to accommodate approximately 3.5 million people. There are 5.5 million people living in the State. The reason emergency departments are so badly overcrowded is because they have been significantly underfunded. The years of massive underfunding happened just after the banking crash. That underfunding has left our system significantly corroded. We have 6,000 fewer beds than we did in 2008. Even the HSE has admitted that we have 200 fewer ICU beds. We have 30% too few GPs. We are missing 700 consultants. In 15 years, Governments have closed eight emergency departments.

It would be great if the Minister and the Minister of State were not having a chat with each other. We do not get much opportunity to converse and a little bit of listening would be great.

The fact that successive Governments have closed eight emergency departments in 15 years is one of the most frustrating aspects of this process.

I cannot fathom why the HSE cannot draw the dots between an accident and emergency capacity crisis and eight accident and emergency departments just after having being closed. It is surely so obvious. The most frustrating thing is the HSE is still wedded to the objective of closing accident and emergency departments. Even in the middle of accident and emergency capacity crisis, the HSE is actively looking to close the accident and emergency department in Navan. There is a serious dysfunction at the top of the HSE and the Minister knows this better than anybody else. He has had enormous battles with HSE senior management during his tenure. The Department fights with senior HSE staff on a regular basis. By way of a small example of this dysfunction, the HSE forced through an ambulance bypass of Navan accident and emergency department before Christmas. The Minister did his best to fight against it but the HSE managed to get it through. What happens now is that ambulances pick up patients in Meath and bring them to Drogheda, where they are triaged. As Drogheda is not able to deal with them, they are brought back to Navan by ambulance and if no ambulance is available, they are brought back in a taxi accompanied by a medical staff member to make sure they are okay, who then has to get a taxi back to Drogheda. It is absolutely amazing that anybody could have the creativity to design so dysfunctional a system. There has to be reform of HSE senior management in terms of where we are going in this regard. There has to be some level of cohesion between the Department of Health and the HSE if we are ever going to fix this issue.

There are many issues, including a lack of funding for GP care. People cannot get to a doctor for a couple of weeks. Many people cannot get onto a GP list and therefore have no choice but to go to an accident and emergency department. Today, there are approximately 500 people who have been clinically discharged from hospital, which means the doctors have done everything they can for them and they should not be in a hospital bed. They should be at home with a home care package, in a nursing home or on another pathway to another hospital, the national rehabilitation centre or another area of the health service that can help them, but that service is not there. I found out through a response to a parliamentary question that dozens of people are clinically discharged in our hospitals for over six months and that the longest a person was in a hospital while being clinically discharged was two years. Imagine being in a hospital bed for two years knowing the hospital could not help you in any way and that the hospital wanted to move you to another location. How would it feel to be trapped and imprisoned in that situation? It is an incredible thing.

There has to be radical transformation. Money has to go to the front line. If the Minister can do anything, he should consider activity-related funding, whereby hospitals only get paid by the number of operations they carry out, the number of treatments, the number of consultations etc. Then we would not see the money getting snarled up in layers of middle management in the HSE.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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What the Deputy described latterly certainly was not creativity, insofar as patient movement is concerned. I do not know how you might describe it. I am sure the Rural Independent Group will have some light to cast on all of this.

Mattie McGrath (Tipperary, Independent)
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The light I have to cast on this is that we have 6,000 fewer beds than we had in the 1980s but we have had countless numbers of extra recruitment campaigns. The Minister announces all the jobs and recruitment campaigns every day. Where are they? They are not on the front line. They are not nurses or doctors.

Stephen Donnelly (Wicklow, Fianna Fail)
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They are nurses.

Mattie McGrath (Tipperary, Independent)
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They are inside in offices and they are pen pushers. When we had the matrons running the hospitals, they were impeccably clean and sterile environments and they ran them from the front door to the back door, and consultants listened to them. Now we have ward managers, floor managers, bed managers, linen managers, hygiene managers, food managers, and discharge managers. We have managers for everything and nobody managing anything. It is absolute chaos. What happened after Christmas will happen next Christmas, as sure as the three Ministers are sitting over there. It is just incompetence. Hospital services have been closed down. The vast majority of consultants have disappeared. There is a skeleton staff on the front line who worked, might and mayhem, I want to support them but they are not getting the support. We saw one of the most senior people resign in disgust and despair two or three days ago. I heard him say on Friday that he could do nothing with it. He came with a wonderful CV but he was not wanted because he did not get the co-operation. It is shocking situation.

I refer to a long-standing centre, the Circle of Friends cancer support centre, in Tipperary town. It had a new building built and has received fabulous support from the community. It has fabulous volunteers with limited staff. They need to be on a permanent funding basis to deal with people suffering from cancer and needing palliative care. The centre has put in a funding application and hopefully it will be successful. They need to be funded.

There are more Ministers in the Chamber. I do not know how many there are. Are there four or five?

Anne Rabbitte (Galway East, Fianna Fail)
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The Deputy can count; one, two, three.

Mattie McGrath (Tipperary, Independent)
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They are not making much of a difference. The Minister of State, Deputy Butler, read out to me nothing short of a diatribe on Carrick-on-Suir hospital. She should be ashamed to close it in her backyard and tell me this and that are going on. The Minister has a fine big empty monstrosity of a white elephant for a primary care centre while that is going on. He should not be trying to cover his tracks in closing a very good hospital. It is shocking.

Michael Collins (Cork South West, Independent)
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West Cork has a crisis in SouthDoc. We have an ambulance crisis and a mental health crisis, and no one is responsible. The responsibility of the continued crisis is Cork University Hospital, CUH, lies with the Minister of Health, the previous Ministers and the HSE. Fianna Fáil and Fine Gael have continuously downgraded services at Bantry General Hospital and got away with it. They closed the overnight accident and emergency department in Bantry a few years ago. No matter how many people tried to explain the consequences, the Government did not give a damn. Now we find the injury unit in Bantry hospital having to close in the past two weeks if staff are sick. This is insane, meaning people from Ardgroom, Castletownbere, Ballydehob, Schull, going east to Kinsale, Clonakilty and Bandon having to go to CUH, which is overcrowded, for simple procedures. Is the Minister aware, as I am, that ambulances are being ordered to take patients to CUH, bypassing the state-of-the-art Bantry General Hospital for treatment of a small breakage in their bones? In some cases, people are going 130 km to an overcrowded CUH and in many cases - the Minister is not listening because the Minister of State, Deputy Butler, is talking to him - people wait hours in an ambulance due to the overcrowding when they could have been dealt with locally at home, within two hours. Why can the Government not get this right? The Minister of State, Deputy Butler, might listen to this part because it is for her. When she visits west Cork herself, she might explain the decision by the HSE to withdraw its appeal against the Mental Health Commission decision to close beds in Bantry General Hospital mental health unit last week. This will have enormous consequences for the people of west Cork and beyond. I accuse Fianna Fáil of being asleep at the wheel on this issue, so much so that its own Deputy in west Cork welcomed the news, if the newspaper that carried the article is to be believed. It is astonishing, to say the least, that this decision would be welcomed by Fianna Fáil. It paves the way for bed closures in the much-needed Bantry mental health unit, going from 18 beds to 15. To think the Minister of State, Deputy Butler and the then Taoiseach, Deputy Micheál Martin, were at the hospital promising more services last year. This is due to a lack of investment by this and previous Governments. This is at a time when mental illness is at an all-time high. When this was first announced last September, I pleaded with the Tánaiste and the Minister of State to intervene. I now plead with her again, and the Taoiseach this time, to intervene that there would not be a loss of beds in Bantry mental health unit.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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It is perfectly reasonable that the three Ministers would engage with one another on matters that Members raise. Members engage with one another all the time in order to give the best possible response. I am not going to criticise the Ministers for engaging with one another on the very valid points that he raises.

David Cullinane (Waterford, Sinn Fein)
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Hear, hear.

Danny Healy-Rae (Kerry, Independent)
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I am glad to have the opportunity to speak on this very important issue. When we talk about health in Kerry, we know people suffer immensely when trying to get into University Hospital Kerry. There are waiting times and people are waiting on trolleys. Ambulances are arriving and the staff cannot take in the patients from the ambulance. That is not acceptable. The ambulances are held up, the patients are held up and the whole thing is a disaster. We have to go back 12 or 14 years when there were wards closed in Tralee hospital, which have never been reopened. We have to start there. Health is a priority in Kerry and it needs to be treated as such.

Never before have so many people died in Kerry than in the past six weeks. We do not know what it is. People of all ages have died, including our lovely, talented Saoirse Buckley, who was 16 years of age, and her neighbour, 97-year-old Nellie Lovett. Today, I learned that Hannah O'Shea, who was 107 years old, has died. So many people of different ages, and those in between, have died.

I was glad to give a 98-year-old lady the opportunity to go up to the North on Wednesday morning at a quarter to four. She is 98 years old and she walked up into the bus, determined as anyone of 50 years of age.

She walked up without a stick, a crutch or anyone assisting her but she had to travel for eight or nine hours up to the North of Ireland to get her sight back. I am proud to have been part of arranging that service with Deputy Collins back in 2017. We have taken 110 buses up so far. However, it is very hard on those people of great ages to travel that distance-----

Danny Healy-Rae (Kerry, Independent)
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Have I gone into someone else's time?

Mattie McGrath (Tipperary, Independent)
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Yes.

Richard O'Donoghue (Limerick County, Independent)
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The Minister organised a meeting last week at which the Taoiseach and the CEO of the University Hospital Limerick, UHL, group were present along with Deputies and Senators with regard to overcrowding at UHL. The first day I came here, I asked for the help. Two and a half years ago, I brought to the attention of the Dáil - it is on the Dáil record - the structure of UHL. The meeting last week showed that the sitting CEO has been in charge of the UHL group for ten years, during which time it has recorded the highest number of people on trolleys and the number gets higher year on year. It is putting the patients and health professionals at risk with regard to fire safety alone. I spent 24 hours in there after a car accident in February when I saw first hand where there were sheets blocking off doors in order that one would not see people on trolleys. I asked for the Minister's help.

Now we can see the CEO is not capable of managing this hospital. There are ten years-----

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Please, Deputy, be very careful. You are making an allegation against somebody who is not here-----

Richard O'Donoghue (Limerick County, Independent)
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Sorry, Ceann Comhairle. I will listen to you.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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You are going beyond the political charge.

Richard O'Donoghue (Limerick County, Independent)
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I am not.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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You are.

Richard O'Donoghue (Limerick County, Independent)
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I am sorry, Ceann Comhairle. I hope you will allow time for me to explain with regard to the comments you made. The hospital has been this way for ten years. Media have been showing it since day 1. "RTÉ Investigates" went in to show it first hand. Peoples' lives are at risk. Are you telling me that if I were a manager of a company for ten years which got worse and worse, I should not leave my job? You pulled me up even though the evidence is clear, not only from me, but from every other Deputy who has spoke against this hospital-----

Stephen Donnelly (Wicklow, Fianna Fail)
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I will speak on a point of information. With respect, regardless of the Deputy's views, many of which I understand are aired on social media, he is in here under privilege calling directly for the resignation of a public servant-----

Richard O'Donoghue (Limerick County, Independent)
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Yes.

Stephen Donnelly (Wicklow, Fianna Fail)
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-----who has no platform such as this to defend herself. I ask the Deputy, as Minister, to stop and to withdraw his request. By all means, he may criticise me or Government but I ask him, please, not to single out individual workers within the HSE of whom he may have a view. I ask him to stop calling for people to resign when speaking under privilege and to withdraw his request. By all means, he may continue with criticisms of me, Government or Ministers. However, the Deputy is referring to an identifiable individual.

Richard O'Donoghue (Limerick County, Independent)
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The House has asked me before not to identify names which I did not. I went by the Ceann Comhairle's instruction, but I did say, "the CEO".

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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Please, Deputy. We will give you the additional time.

Richard O'Donoghue (Limerick County, Independent)
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Okay.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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There is only one CEO. Thus, the person is readily identifiable.

Stephen Donnelly (Wicklow, Fianna Fail)
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He or she is.

Richard O'Donoghue (Limerick County, Independent)
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You asked me not to mention the person's name.

Seán Ó Fearghaíl (Kildare South, Ceann Comhairle)
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It is not fair. You are a decent man. It is not fair to come into this House and name somebody who is not in a position to defend himself or herself before the House.

Richard O'Donoghue (Limerick County, Independent)
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I will not withdraw what I have said. I will stand over it for the protection of the people of Limerick, north Kerry, north Tipperary and Clare. I have asked the Minister for help. I understand where he is coming from - I really do - but I have to protect the people of Limerick and the surrounding areas who have asked me to protect them. Under fire safety alone, the fire certificate is invalid for the number of people in that hospital and the Minister is asking me to withdraw my comments. I will not.

Stephen Donnelly (Wicklow, Fianna Fail)
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About the individual.

Michael Healy-Rae (Kerry, Independent)
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The main problem we have in County Kerry starts out in the community, that is, people being able to access a local GP. Whether it is in Waterford or south, east, mid-, north or west Kerry, getting access to the local GP is the problem. Trying to make it attractive for GPs to live in our communities as they did before and provide a local service is the biggest problem we have. We should give that service in the communities on a 24-hour basis. I appreciate very much the work that SouthDoc does. I appreciate the drivers. I appreciate Dr. Gary Stack in Killarney and the other people who organise it and have always been to the forefront of keeping SouthDoc going in County Kerry. I thank every person who provides the service.

However, we still need more doctors. We have had excellent doctors. The Minister is talking about naming people negatively. I wish to name people positively. I will name my own great doctor, Dr. Boland, who represented Kilgarvan and Kenmare for decades and gave Trojan service 24 hours per day, seven days a week. It is the same thing with the two doctors O'Driscoll in Kenmare. They are great people who gave a great service.

Unfortunately, it is not attractive anymore, from a business point of view, for a person to come along, operate out of a facility, have insurance and provide that service locally. We have to do more to make it attractive. If we can do that, we may be able to keep people away from hospitals and keep accident and emergency departments free for what they are supposed to be free for, that is, accidents and emergencies.

There is a tremendous problem in Kerry University Hospital at present when a person goes there. It is not acceptable. I have said before that if a cow goes down tonight and that cow needs a vet, it would be absolutely outrageous to think the vet would not be there in one, two hours or three hours. It would be outrageous. The cruelty-to-animal people would be down on top of you and everybody would say you were a scandal to have a cow in pain, have something wrong with her or have her needing an operation. However, no notice in the world is taken where a person is in an accident and emergency department for 24 hours or two or three days.

Richard O'Donoghue (Limerick County, Independent)
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Losing his or her life.

Michael Healy-Rae (Kerry, Independent)
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How have we gone so wrong that healthcare is available to animals quicker than it is to people? The Ministers are the Ministers for Health. I am not coming down on them but I am at the same time. An animal can be treated more quickly in Ireland today than a person. That is wrong and, to be honest, it is a reflection on the Ministers.

Thomas Pringle (Donegal, Independent)
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The current situation in our hospitals is devastating and completely unacceptable. Our health service is at breaking point and it is clear that total collapse is not far away. The overcrowding crisis is catastrophic and will continue to get worse if drastic measures are not taken as soon as possible. Yesterday, Letterkenny University Hospital in my constituency was the second-worst affected hospital in the country with 54 patients waiting on trolleys. I cannot imagine how stressful the situation is for those 54 people and their families. It is not only totally inhumane to have so many left waiting for a bed, it is also extremely dangerous. It is estimated that hundreds of people die in Ireland each year due to the overcrowding situation.

This Government and previous Governments should be ashamed of themselves. The severe shortage of beds in our hospitals is not a new problem. It has been raised in this Chamber every winter for decades. Unsurprisingly, the politicians behind the crisis have not changed either and that says it all. We had the Taoiseach as Minister for Health from 2014 to 2016 and the Tánaiste as Minister for Health from 2000 to 2004. Not only have things not improved in more than 20 years, they have gotten worse.

The Tánaiste will remember the capacity review conducted in 2002 after which the Government committed to providing for an additional 3,000 acute hospital beds. Despite this commitment to provide more beds, Fianna Fáil and Fine Gael Governments have not only not followed through on this, they have allowed the number to drop continuously over the past two decades, with a significant dip after 2008.

The Government always says the Opposition has never proposed solutions. In the past year, I have proposed that the Minister look to employ Cuban doctors to alleviate the crisis within the health service which is feasible and doable and which other European countries do all the time. Portugal, Italy and Sweden have done it all. I have written to the Minister, but have not got a reply. He has not even responded and acknowledged having received the letter with regard to this. It is there, if the Minister asks for it. Those doctors can help to alleviate the problems we have in the short term, while we are trying to implement the other measures with regard to graduating further doctors. That could be done but, obviously, the Minister is not interested.

Catherine Connolly (Galway West, Independent)
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I thank Sinn Féin and I support the motion. However, having been elected in 2016, I really wish I was here with a motion from the Government and an update on Sláintecare and the primary care strategy in order that we could all participate. We have been through this song and dance, have we not, at every single election? Public health, housing and transport, dealing with climate change and our wanting to pay taxes is the message. Thus, we came together and a cross-party report was produced, Sláintecare, showing the way forward.

I know the Minister is doing his best. I have seen it on the ground and I pay tribute to some of the changes that have come in.

However, we are left going from crisis to crisis. I had cause to be in the emergency department last week for somebody close to me. I was lucky that day in that there were nine people on trolleys. One week later, in Galway, there were 46 people on trolleys. Staff are working full-time. The problem is complete under-resourcing for donkey's years, a commitment to private medicine, diversion of our public money into private medicine, and a National Treatment Purchase Fund that is looking at waiting lists that have been deliberately built up. I spent ten years of my life on a health forum and saw all the excuses. The Minister is inheriting a system but is also part of a system that has refused to say public health needs to be like public housing.

Many things are needed, including more doctors and nurses, and proper conditions. I am in a city where the nursing home in Carraroe has not put back daycare. I know both of the female Ministers of State present are deeply committed to this. There is no day centre in Carraroe and no staff for one. Clifden District Hospital closed over Christmas and there was nowhere to take the pressure off it. I could name the places that have been affected. A fantastic day centre has been moved from Loughrea. Councillor Donohue, the independent councillor, moved it to a hotel. The daftest decisions have been made. Where is the roll-out of primary care? In Connemara, a woman in her 90s had to go into Galway for blood tests because blood tests were not done in Connemara on a Friday. The ECG machine had broken down, so somebody else had to go in for that.

In my own case, somebody close to me avoided the emergency department like the plague to their cost. That patient should have been in the emergency department on Wednesday but we avoided it until Friday. We are making decisions that are detrimental to our health. We are not rushing up to the emergency department. We need the Government to provide a progress report every month on the roll-out of Sláintecare.

Joan Collins (Dublin South Central, Independents 4 Change)
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I found it astounding and outrageous that when outlining his top priorities as Taoiseach, Deputy Leo Varadkar did not even mention the health crisis in this country as one of his priorities. The implementation of Sláintecare was supposed to be directed from the Taoiseach's office but it has not been. That office should have responsibility to drive it. There has to be political will to deal with its implementation. This clearly shows the attitude of this Government that these problems cannot be solved, so we just move from crisis to crisis. The political will has to be there. This is all while we have a record number of people in our emergency departments, with close to 1,000 people on trolleys, chairs and, in some cases, on floors. The fundamental cause of this crisis is the reduction of beds in our health service over the past three decades. In 1981, we had 19,000 hospital beds. In 2022, we had 12,000 hospital beds. This is in a period where our population has grown by 1 million and got older.

Experts suggest that the lack of timely access to healthcare in the country could be responsible for more than 300 unneeded deaths every year. This is simply not acceptable. Almost one person a day dies because of a public health service that does not function and does not give people access to the care to which they are supposed to be entitled, despite the Trojan work hospital staff do every day of the week. If the Government does not act now, it means it is continuing to accept the situation.

The Irish Medical Organisation has called for a further 5,000 beds to help to fix this problem fundamentally. The cost of that is roughly the same as the €5 billion budget surplus the Government has, so funding should not be an issue in providing those 5,000 beds over the next period along with the necessary staffing. We need to end the crisis in recruitment and retention and to provide better training and opportunities. We should be thinking outside the box by delivering a programme to train doctors, nurses, therapists and so on. The State should pay for that training and get those workers to commit to staying in the country for at least eight years as a way of resolving the retention crisis. We need to end the terrible working conditions for staff. Burnout is at an all-time high and this Government is sleepwalking into a conflict with the nurses' union. It would help if young people working in the health service could afford to live in this country. We cannot see a repeat of the climbdown. This Government should proceed with the reforms of consultants' contracts. Anybody would be willing to accept a job with nearly €250,000 in wages. It is ridiculous.

Marian Harkin (Sligo-Leitrim, Independent)
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The Minister tells us in his amendment that he has delivered record funding to the health service, and that much is true, but a crucial point flows from that, which is that this is taxpayers' money and the Minister's responsibility is to ensure it is well spent. It is not to tell us he has spent it but to ensure good outcomes from that spending. How does the Minister's amendment read to those very sick people who spent their time in corridors, on trolleys, in side rooms and in outside wards over recent months? This affected 120,000 people last year. The Minister is really saying to them that the Government spent more of their money than ever last year but they are still on a hospital trolley. I looked at Sligo University Hospital. A total of 783 people were on trolleys in the month of November, but the Minister is telling those people he has provided certain things, which he has, but that the problem is that too many of them are getting sick and that if fewer people got sick, we would not have this crisis.

The job of Government is to plan and implement that plan in a timely way to deal with the reality of the situation. The Government has reacted too late. The winter plan did not deliver. The Government did not mobilise all of the private beds in time to deal with the crisis. We have a chronic shortage of beds but I do not need to tell the Minister how that has come about and whose responsibility it is. We see smaller nursing homes closing while many people are ready to leave wards, but they cannot because there is no long-term care facility available.

For the past two and a half years, the Minister has watched nurses and doctors emigrate. In the past week, a consultant who has come back from Australia told me that there are more Irish emergency department consultants in Western Australia and Perth than in all of Ireland. Those are some of the reasons we have the appalling trolley crisis. Some of these issues are within the Minister's control and some have been badly managed.

Mary Butler (Waterford, Fianna Fail)
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I welcome the debate and support the amendment moved by the Minister, Deputy Donnelly. I believe in the delivery of fundamental public health services to the highest standard. The Sinn Féin motion was all about taking political aim. It is very personalised. It failed to take into account any of the significant investment in our health services and the policy measures already in train to increase capacity in our health service.

Today, there are 137,220 whole-time equivalents working in public healthcare. As we stand here tonight, they are working. They will work tonight, tomorrow and the day after. There are 137,220. I sincerely thank every one of them. Since 2020, 17,403 more people have entered the public health service, including 5,169 nurses and midwives, 2,870 health and social care professionals, and 1,800 doctors and dentists. Those are facts, not fiction.

Recently, our population was hit by three viruses, which were influenza, Covid-19 and RSV, at the same time. I accept and acknowledge how difficult it was for patients, staff and families. None of us here wants to see any person on a trolley. None of us wants to see an older person on the trolley. It could be any of our families. We have worked tirelessly to try to resolve this. The Minister, Deputy Donnelly, has been working with the HSE since early summer to put in place plans for winter. The winter plan is supporting delivery of a range of actions to optimise available capacity across community and hospital services by expanding GP access, including within the GP out-of-hours service, facilitating patient flow through the hospital system, and supporting safe and timely discharge. We have allocated up to €169 million to make this happen this year.

When demand in our health services spiked, the Minister instructed the HSE to provide for additional out-of-hours cover, including from senior decision-makers. Diagnostic teams, radiology teams and laboratories worked expanded hours too, as did allied health professionals such as physiotherapists, since their roles are fundamental to ensure the full scope of discharge requirements is available. The HSE directly engaged with private hospitals ahead of Christmas and asked for any additional capacity that was available.

Additional GP supports have been made available to enable GPs to extend existing clinics. The measures allow more patients to see more GPs. I echo the thanks expressed by the Minister and the Minister of State, Deputy Rabbitte, to all the front-line workers. We are truly grateful to them, and we are doing our best to add to their numbers.

There are plenty of examples of good practice across our health system. In my constituency of Waterford, University Hospital Waterford has succeeded in staying trolley-free for over two and a half years. This is an incredible achievement and it must be acknowledged.

Anne Rabbitte (Galway East, Fianna Fail)
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Absolutely.

Mary Butler (Waterford, Fianna Fail)
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University Hospital Waterford continues to perform better than the national average for patient experience times in the emergency department, ambulance turnaround times and maintaining a zero-trolley status for admitted patients, and all with a view to supporting a positive patient experience with 452 beds. This has been achieved through close co-operation between University Hospital Waterford, UPMC Whitfield Hospital and three private nursing homes to bring on stream additional capacity of more than 45 beds in the catchment area. This was not just done in the past few weeks; it was done over the past two years and it has made a significant difference. It means patients who no longer need consultant-level care in acute level 4 hospitals can be transitioned safely and securely for local nursing care while they continue their care pathway. A dedicated focus on patient egress through University Hospital Waterford - led by Grace Rothwell, the manager of the hospital, with the co-operation and support of all the staff - has resulted in it not having to rely on trolleys.

The Government recognises a strong healthcare system goes far beyond our hospital doors and we know many older people would much prefer to stay at home. We have the community intervention teams. We have all 22 integrated care programme for older people teams in place. We have home and community nursing units. Without these teams and vital community healthcare networks such as St. Brigid's in Carrick-on-Suir, many patients would have to be seen in hospital. The teams on the ground support people living with long-term illness, pain management and diabetes. In addition, without these teams, many patients fit for discharge would have to remain in hospital. Timely access to home support is critical to supporting older people and people with disabilities to live and age well in their communities. The most up-to-date figures show that 56,500 people were in receipt of home care today. There are 3,240 new applicants with funding approved waiting for a carer and 2,819 people are already receiving some supports but not the maximum hours advised. Home support is important in helping many older people leave hospital safely.

We recognise the workforce challenges affecting access to home supports and I have strongly endorsed all 16 of the recommendations of the strategic workforce advisory group. We are committed to the full implementation as a priority. On 16 December last, in conjunction with the former Minister of State, Deputy English, I announced the authorisation of 1,000 employment permits for non-EU or EEA home support workers, as recommended by the advisory group. I am very hopeful this will significantly reduce the shortage of home support workers in Ireland in the immediate future. A similar measure was successfully provided in nursing homes and the HSE community nursing units, with over 2,500 permits issued up to last year. Rolling recruitment campaigns across the HSE also continue to encourage people to see home care as a viable career opportunity. The payment of the living wage and mileage, which were also dealt with in the report, will be in the new HSE tender at the end of March.

I wish to speak about the enormous ongoing efforts to support the safe discharge of patients from the acute hospitals into the community as soon as possible. The HSE national service plan includes several initiatives to support this and transitional care funding is available to ensure patients can move into a nursing home temporarily while their applications for fair deal funding are being processed. This funding is available all year round, with €16 million being specifically allocated through the winter plan. As a continuation of the winter plan initiatives, the HSE is working to ensure the full utilisation of 654 contracted private nursing home beds that have been brought on stream through the community beds initiative. The initiative has been in place since 2011, when €125 million was first allocated to develop short-stay residential and rehabilitation capacity. These beds are contracted nationally and enable patients to be discharged from our acute hospitals into nursing homes while awaiting transfer either home or into long-term residential care. Under these initiatives, patients transfer into community beds regularly. Last year, 10,000 patients were able to access temporary care funding. In the first week of this month alone 267 patients transferred from acute hospitals to long-term care in residential homes. This is double the number for the same week in January last year. There was also nearly 1,000 approvals for transition into nursing homes through the month of December 2022.

It is recognised that capacity for transitional care will vary across the country. I continue to encourage engagement between nursing home providers and the HSE at a local level to agree suitable measures to meet the needs. Such agreements are already in place and have been effective in reducing delayed transfers of care. The HSE estimates that there are 221 patients awaiting transfer to long-term residential care. I have written to the HSE to ask it to encourage all community healthcare organisations to maximise their use of existing transitional care funding as needed. I have also advised it of my support for extra initiatives regarding home support to free up acute capacity.

I was recently contacted by concerned older people and their families. They expressed the fear that if they attend an acute hospital, they may have difficulty in returning home and that long-term residential support may be a choice offered. I emphasise the importance of at all times hearing, respecting and ensuring that the voice and choice of older people remains central to decisions regarding their care. Many of the supports and capacity I have outlined refer to short-term supports until a person is suitably well to return to their own home. I take this opportunity to thank all the staff of the health service for their work to engage in providing surge capacity in respect of home support.

Every part of the healthcare system, including primary care, social care and community care, is seeing additional investment to build for Ireland's future. When these are put together, they can be used to achieve the reform we all want.

Patricia Ryan (Kildare South, Sinn Fein)
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I thank my colleague, An Teachta Cullinane, and his team for bringing forward this motion. Even the most unbiased eye can see our health service is in turmoil. Unfortunately, this is not a new problem. Successive Fianna Fáil and Fine Gael Governments made decisions that caused the crisis we are in or failed to make the decisions necessary to avert it. There are three former Ministers for Health at the Cabinet table with the current Minister. They must all bear responsibility for this mess.

We in Sinn Féin have detailed plans to address the crisis in our health service. In government, we will increase spending on healthcare by €3.3 billion to move from a failing two-tier health system to universal healthcare. More importantly, we will ensure the health budget is spent wisely by talking to front-line workers and patients. Their experiences must be taken into account. We need a major review of how recruitment and retention are managed. In government, Sinn Féin will recruit 6,600 additional front-line health workers, including nurses, midwives and consultants. We will review all vacancies and put in place a plan to do whatever is necessary to fill them. Despite the impact on patient care, there is no urgency on the part of the HSE to fill vacancies. To date, there has been no proper multi-annual capital plan for reaching the necessary capacity at all hospitals and that is not good enough.

It is 17 years since the actor Brendan Gleeson called out the disaster zone that is the health service on "The Late Late Show". It is 16 years since Fine Gael asked the people to sign the contract for a better Ireland. It is 12 years since Enda Kenny promised to end the scandal of waiting lists and patients on trolleys. It is a few weeks since a national newspaper reported the experience of a patient who witnessed the death of another patient on a trolley in a hallway in one of our hospitals.

The Minister of State, Deputy Butler, spoke about the elderly. I am my party's spokesperson on the elderly, and I can tell her that I have been inundated with messages from people whose family members were lying on trolleys in Naas Hospital over Christmas. I am not accepting that not everybody is on a trolley. Front-line workers are doing their best in appalling circumstances. This is what it has come to. The lack of dignity is an absolute disgrace. The Minister and the Ministers of State should be ashamed of themselves.

Pearse Doherty (Donegal, Sinn Fein)
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Everyone knows someone who is waiting on an operation, is in therapy or is unable to get a much-needed appointment. We all know our health service is not working. It is plagued by overcrowding, which is putting patients at risk and condemns our healthcare staff to working conditions that they simply should not have to put up with. The crisis has been brewing for some time and has gotten so bad that patients and their families have almost come to accept that it is normal. It is not acceptable and it is not normal. The people of my constituency in Donegal cannot trust Fine Gael with our health service. On Monday, 66 people were waiting for a bed at Letterkenny University Hospital, which was the highest number in the State. Last year, more than 7,000 patients went without a bed at Letterkenny University Hospital. It was the worst year for overcrowding on record and more than a tenfold increase since Fine Gael took office.

The people of Donegal deserve so much better but the decisions of successive Fianna Fáil and Fine Gael Governments have caused this crisis and made it worse. Two weeks ago, the chief executive of the Saolta Hospital Group, which includes Letterkenny University Hospital, said it had not received a single additional bed in the past three years. These failures are repeated throughout the State. There are fewer hospital beds now than there were 20 years ago, despite population growth and the economic growth that this Government so often brags about but is so clearly squandered.

The failure of this Government cannot be allowed to breed cynicism in our health service so it is condemned to failure. The situation can improve because there are solutions there. We need to make greater use of all public and private healthcare infrastructure to alleviate the pressures. We need to increase the number of public beds and speed up admissions and discharges. We need to ramp up the number of training places to ensure we recruit and retain the required number of healthcare staff. A long-term workforce development plan is needed urgently. This can be done but the truth is that successive Governments have failed our health service for far too long. Sinn Féin has a plan, put forward by our health spokesperson, Deputy Cullinane, that would address the crisis in our hospitals, would put patients first and would show that we can turn the tide on the disastrous policies of Fianna Fáil and Fine Gael. I call on this Dáil to support the motion put forward by Deputy Cullinane.

David Cullinane (Waterford, Sinn Fein)
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The speeches this evening from both the Minister, Deputy Donnelly, and the Minister of State, Deputy Butler, were breathtaking. In response to an emergency in our hospitals, the Minister's biggest complaint was that Sinn Féin did not give him a pat on the back for the good work he believes he has done. That was his chief complaint, repeated time and again in his script. The Minister of State, Deputy Butler, was concerned that we were too robust in our criticism of Ministers past and present. In fact, we were not robust enough because successive Governments are directly responsible for failing to properly equip our health service. What was absent from both of their contributions - I asked for it but it did not come - was any responsibility whatsoever for what has happened. There was no responsibility for patients on trolleys in record numbers, no responsibility for people lying on floors in emergency departments, no responsibility for older people over 75 waiting days on end in hospitals for care and not getting it, no responsibility for the fact that people could not access out-of-hours GP care. They took no responsibility for the fact that front-line healthcare staff are telling me every day of the week, and I am sure they are telling the Ministers as well, that they are broken. They are working huge amounts of overtime. In fact, the situation in our hospitals would be a lot worse today if not for the escalation emergency measures that were taken and people being asked to do more work on the front line, doing overtime that is actually dangerous. There has been no acknowledgment from the Minister or Minister of State.

Not only was there no responsibility, there was no apology from the Minister for Health. At least the head of the HSE had the gumption to apologise for what happened. This Minister was concerned that we in Sinn Féin did not give him a pat on the back, never mind giving an apology. Let me remind the Minister again of what I said earlier. Yes, there are things he has done that I recognise as important. Things have been delivered that will make a difference. I welcome any additional resource in healthcare. I have said to him for a long time what needs to be done to fix problems in our emergency departments. All the commitments that were given to end the trolley crisis and deal with waiting lists were promises and commitments the Minister made. I am holding him to account for promises he and successive Governments have made. They are the ones that said they were going to fix the problem but year on year, month on month and day on day, the situation gets worse.

There are four things we need to do. First is to start with the hospitals. We know we need more beds, more staff, more consultants, doctors, nurses and so on. We need more diagnostic capacity. More GP access to diagnostics is welcome but we need more capacity in the hospitals to ensure we can speed up patient flow in hospitals The lack of capacity is slowing things down. We need elective-only hospitals delivered as quickly as possible to separate scheduled and unscheduled care as much as we can. We need to double capacity in the National Ambulance Service and we need to make greater use of level 2 hospitals and of private hospitals for the public good. We need to do all of that and more.

The second thing we need to do is once and for all take workforce planning seriously. The Minister said in his opening statement that we need to double training capacity. He keeps saying it but he is not doing it. We are nowhere near it. In fact, the Secretary General of the Department, when he was before the Joint Committee on Health, acknowledged that what needs to be done in terms of workforce planning is not being done. The Minister should stop telling us what needs to be done as if he is some objective commentator. He is the Minister for Health. He should put in place the measures to substantially increase training capacity and a proper workforce plan once and for all. If we do not have the workforce plan we cannot train, we cannot recruit and we cannot retain the healthcare professionals we need to open the beds, provide the diagnostic equipment and provide all the care in the community. We need the right care in the right place at the right time. The Minister of State, Deputy Butler, talked about all the community intervention supports and supports for older people. Lots of those teams are not properly staffed. We do not have enough GPs. We are not making use of community pharmacies. There is a huge amount we need to do in terms of community care. I do not have time to go through it all. That is the third priority.

The fourth is reform. The Minister said this himself and it is one of the things I agree with. We need better management. That is a fact. In some hospitals there should be better management. I do not agree with what was said by some Deputies in the Chamber around singling out any individual managers but I believe we need best practice across all hospitals. The responsibility for driving that change and making sure managers and hospitals are actually given the resources to do the job lies with the Minister. After everything that happened, after everything all of those on the front line have gone through and all the suffering of patients, there is no responsibility, no apology, no leadership and no vision from the Minister and his Government colleagues. That is shameful.

David Cullinane (Waterford, Sinn Fein)
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Vótáil.

Bernard Durkan (Kildare North, Fine Gael)
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In accordance with Standing Order 80(2), the division is postponed until the weekly division time on Wednesday, 25 January 2023.